Healthcare Provider Details

I. General information

NPI: 1245625573
Provider Name (Legal Business Name): DISTINGUISHED DIRECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 WILDOL ST
HOLLY HILL SC
29059-8545
US

IV. Provider business mailing address

324 WILDOL ST
HOLLY HILL SC
29059-8545
US

V. Phone/Fax

Practice location:
  • Phone: 803-971-1585
  • Fax:
Mailing address:
  • Phone: 803-971-1585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAREKIA FELDER WEARING
Title or Position: OWNER
Credential:
Phone: 843-779-5752